How the Plan Works | Benefit Schedules | Eligibility and Enrollment

Individual and Family Dental PPO Plan Coverage
UNICARE Life & Health Insurance Company offers the Individual and Family Dental PPO Plan to help keep your teeth healthy and your smile bright. The UNICARE Individual and Family Dental PPO Plan gives you the option of going to any dentist you choose. Hundreds of dedicated professionals have contracted with UNICARE Life & Health Insurance Company to provide a wide range of dental services such as routine check-ups, cleanings, fillings, crowns and dental surgery.

The plan was designed with two goals in mind. The first and foremost is to promote good dental hygiene and preventive care, important elements in a total health care package. The second goal is to provide you with the dental care you need in a convenient, cost-conscious manner, thus providing many dental services at reduced costs.

The plan features low-cost preventive and diagnostic care, basic dental care, and a benefit schedule that can help you offset the high cost of major dental care. Please read the following information for details about how the plan works, specific benefit information and certain exclusions and limitations that apply.

How the Individual and Family Dental Plan Works
A large number of dentists in Georgia have agreed to provide services at contracted rates to UNICARE plan members and are known as "preferred" dentists.

When you choose a preferred dentist, you will receive care at negotiated discounted rates – what we term "The UNICARE Advantage." Should you choose a nonpreferred dentist, the plan still provides benefits, but your out-of-pocket expense may be greater, as the negotiated fees don’t apply to nonpreferred dentists. You will be responsible for any charges in excess of the stated benefit for both preferred and nonpreferred dentists.

Your current dentist already may be a preferred dentist. Before you choose a dentist, be sure to check the Provider Finder on this site or call UNICARE Dental Services at 1-888-209-7852. It could save you money.

The plan lets you know up front in flat dollar amounts how much the plan pays for the covered services. This means that you are able to calculate easily how much you will have to pay once you have determined your dentist’s fee for the specific procedures listed.

The following is an EXAMPLE of how negotiated fees may save you costs.  Negotiated fees may vary among preferred dentists.

* This assumes any deductible has been met and you have not reached your annual maximum.

Calendar Year Deductible: You are responsible for a yearly $50 per person deductible, with a maximum of three deductibles ($150) per family, before your benefits for covered services are available.

Calendar Year Maximum Benefit: All dental benefits are limited to a maximum $1,000 payment by UNICARE Life & Health for expenses incurred by each enrolled member during a calendar year.

Waiting Periods: Preventive and diagnostic care begins upon approval of your application. Coverage for basic care begins after six (6) continuous months and for major care after twelve (12) continuous months of coverage.

Customer Service: UNICARE Life & Health Insurance Company’s professional dedicated enrollment units are available to assist you and to answer any questions you may have about your plan.The toll-free number is listed on the dental plan identification card you will receive once your enrollment is approved.

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Benefit Schedules
Coverage is provided ONLY for the services stated in the following schedules. To use these schedules, check your dentist’s fee and then determine how much the plan plays. You can then easily calculate what you will pay for a specific service after your deductible has been met. The plan pays either the specified amount, or the actual amount charged by your dentist, whichever is lower. You are responsible for any charges in excess of the stated benefit.

Preventive & Diagnostic Care

• Begins upon approval of your application.
• Calendar year deductible of $50 per person, with a maximum of three deductibles ($150) per family, must be satisfied.
• The benefit schedule is the same for both preferred and nonpreferred dentists, but you may have a greater share of the costs if you choose a nonpreferred dentist.
• Two oral examinations and two dental cleanings per member, per year.
• Total benefit for single and bitewing x-rays not to exceed benefit for full mouth—$47.

Notes:

• Adult  - Any person or dependent 19 years or older covered by this policy.
• Child - Any person or dependent 18 years or younger covered by this policy.

Basic Dental Care

• Coverage begins after the plan has been in effect for six continuous months.
• Calendar year deductible of $50 per person, with a maximum of three deductibles ($150) per family, must be satisfied.
• The benefit schedule is the same for both preferred and nonpreferred dentists, but you may have a greater share of the costs if you choose a nonpreferred dentist.

Major Dental Care

• Coverage begins after the plan has been in effect for twelve continuous months.
• Calendar year deductible of $50 per person, with a maximum of three deductibles ($150) per family, must be satisfied.
• The benefit schedule is the same for both preferred and nonpreferred dentists, but you may have a greater share of the costs if you choose a nonpreferred dentist.

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Eligibility and Enrollment
To be eligible for enrollment, you must be

• A resident of the State of Georgia who properly applies for coverage and is accepted by UNICARE Life & Health Insurance Company
• A resident of the United States for at least six months, age 64 1/2 or younger
• The applicant’s lawful spouse of the opposite sex, age 64 1/2 or younger
• The applicant’s unmarried child up to age 19
• The applicant’s unmarried child who is a full-time student up to age 25
• Not enrolled under any other individual or group dental policy
• Unmarried stepchildren who reside with the applicant up to age 19 or if a full-time student (12 units), age 19 through 22

Date Coverage Begins
The effective date of your coverage is printed on your identification card. Your coverage will stay in effect with our consent, on a three-month basis if you have chosen quarterly coverage, or on a monthly basis if you have chosen the monthly checking account deduction program.

Premium Rates
The rates listed are monthly rates. Monthly payment is available only through the monthly checking account deduction program. If you prefer to pay quarterly, multiply the monthly rate by three.

Counties with strong network access:

Counties without strong network access:
A fewer number of preferred dentists are available in other areas. UNICARE plan members are entitled to the benefits of the negotiated amounts if they choose one of those preferred dentists. Benefits are still available for nonpreferred dentists, as specified by the plan.If you would like your dentist to become a preferred dentist, please have him or her contact us.

Terms of Coverage
Coverage under this plan remains in force as long as the required premiums are paid on time and as long as the insured remains eligible for coverage. If your spouse becomes ineligible for coverage under this plan because of death of the policyholder or divorce, he or she may obtain a similar plan through UNICARE.The new plan will have the same benefits as this plan. Other insured family members who are no longer eligible due to age or who no longer qualify as dependents for coverage under this plan may also obtain a similar plan through UNICARE.To be eligible for this conversion privilege, you must contact UNICARE within 31 days of the loss of eligibility to request coverage. Any and all probationary and/or waiting periods in the new plan will be considered as being met to the extent coverage was in force under this plan. UNICARE may refuse to renew or may change the premiums of this plan after 30 days written notice to the policyholder. However, UNICARE will not refuse to renew or change the premium schedule for this plan on an individual basis, but only for all policyholders in the same class and covered under the same plan as you.

Other Insurance with This Insurer
Insurance effective at any one time on the insured under a like plan or plans with this insurer is limited to the one such plan elected by the insured, the insured’s beneficiary or estate, as the case may be, and the insurer will return all premiums paid for all plans.

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